The factors that mediate developmental handicap in very low birth weight infants are incompletely understood. The primary objectives of this application are to identify and alter the nutritional factors that may constitute a detrimental effect on the developing central nervous system. Although delivery of calories adequate for growth is a worthwhile goal in itself, it may have even greater importance through its impact on neurodevelopmental outcome. Interdigitation with the Core will provide a framework to test the hypothesis that improved nutritional support during the immediate neonatal period will increase rates of head growth as well as somatic growth, and thus, favorably influence subsequent development. Four specific aims characterize this proposal. First we will assess the contribution of early nutrition to rates of somatic growth and to developmental outcome. Two risk scores (one based on caloric intake, one based on duration of PN) will be applied daily for the first six weeks of life for all VLBW infants enrolled in the Core. Second, we will evaluate whether nutritional "improvements" (based on pre-selected markers) have any identifiable developmental correlates. Third, we will identify the effect of carnitine supplementation in parental nutrition (PN) (Study 1). We postulate that carnitine supplementation will lead to improved lipid oxidation, better nutrient utilization for synthetic processes and subsequent improvement in growth. Fourth, we will evaluate potential beneficial effects of supplemental enteral feedings. (Study 2) We postulate that enteral feedings will increase small bowel mass and improve nutrient absorption. Stimulation of gut hormones may also lead to an increase in bile flow, reducing the incidence of PN-associated liver dysfunction. Biochemical parameters, nitrogen balance, respiratory quotient and anthropometric measurements will be the methods used to judge the immediate effects of nutritional interventions. Long term effects will be evaluated through correlation of nutritional parameters with developmental data available through the Core.